What is the biggest mistake you made in a prescription that you dispensed?

A short time after the sleeping pill Halcion was introduced onto the market, I received a prescription for this drug in which the doctor specified the directions “Take one tablet three times a day.”  Obviously, sleeping pills are not taken three times a day.  They are taken at bedtime. 

Believe it or not, pharmacists may not necessarily be aware of the indications (approved uses) for a new drug or the number of times per day that it is usually administered.  With so many new drugs being introduced these days (at least in part because the FDA is under pressure from Congress and the drug industry to relax standards for approvals—according to some critics), it becomes more difficult for pharmacists to keep up.  We have a learning curve with each drug.  And don’t forget that there are a few thousand drugs on pharmacy shelves.

Of course, it is inexcusable that a pharmacist would dispense a drug for which he doesn’t know the indications or how many times daily it’s usually taken, but this is what actually happens sometimes in the real world.  Certainly I was negligent in not checking the official prescribing information before I dispensed this drug.  But the doctor made the original error and I didn’t catch it. 

Pharmacists are very busy people with very hectic lives and families to raise, etc.  Finding the time to keep on top of the flood of new drugs is something to which we should give a high priority, but, in the real world, lots of drugs are dispensed in this country that pharmacists are not “on top of.” 

Part of the problem may be the circus atmosphere surrounding new drugs and pharmacists’ feeling that drug companies are leading us around by the nose, forcing us to learn about their latest wonder drug. 

Allow me to digress for a minute.  It is a fact that a large fraction of the new drugs introduced each year are simply “me-too” or “copy-cat” drugs.  For a detailed explanation of “me-too” drugs, see The Truth About the Drug Companies (NY: Random House, 2004) by Marcia Angell, M.D.  Angell is a former editor-in-chief at The New England Journal of Medicine.  In essence, each pharmaceutical company wants to have a “player” in a “hot” field (blood pressure, depression, cholesterol, type-2 diabetes, etc.), whether or not that drug is any better than existing drugs.  In many cases, the new drugs are no better and, in some cases, they’re worse than existing drugs.  The FDA does not require that new drugs be safer or more effective than existing drugs.  New drugs must be sufficiently different to qualify for a patent.  Drug companies want to get their share of any lucrative disease market.  

In my opinion, it is quite possible that pharmacists’ skepticism toward the flood of copy-cat drugs contributes to a relaxed attitude toward learning about these new products.  At least that attitude has affected me.

Back to the Halcion error.  How was this error discovered?  One day the physician who wrote the prescription called.  I happened to be on duty at that time.  He said something like “Somebody there typed ‘three times a day’ on a sleeping pill prescription I wrote.”  Apparently the patient had brought it to the doctor’s attention. 

Of course, this is an extremely uncomfortable situation for any pharmacist to be in.  It’s our worst nightmare.  The pharmacist’s immediate reaction is to hope that it may have been our partner or a fill-in pharmacist who filled the prescription.  So, before we let the doctor chew us out, we delay things momentarily by saying something like “Let me pull the actual prescription from our files.”  (This was before we scanned an image of the original prescription into the computer.)

It turns out that my initials were on the prescription, so I was the pharmacist who had filled the prescription and made the error.  But wait a minute!  I see that the doctor specifically wrote “TID” on the prescription (the Latin abbreviation for “three times a day”).  I said to the doctor, “I have your prescription in my hand and it clearly says ‘TID’.  You are welcome to stop by the pharmacy and examine it if you like.” 

The doctor’s attitude softened.  Somewhat surprisingly, he did not question the fact that he had mistakenly specified “TID.”  But he asked, “Why would you type ‘three times a day’ on a sleeping pill prescription?”  I didn’t have a good answer, but neither did he have a good answer for his mistake.  So we were basically even (we had both screwed up) and the conversation then ended.  Thank God. 

There could have been tremendous liability involved if, for example, the patient didn’t know this was a sleeping pill.  A huge number of our customers are in a complete fog as to the precise purpose of each medication they swallow.  So, if, for example, this customer had indeed taken it three times a day (not knowing it was a sleeping pill) and then he had been involved in a car accident, the potential liability for me and my employer could have been tremendous. 

In this example, what percent of the fault belonged with me and what percent belonged with the physician?  The doctor made a mistake and I didn’t catch it.  Luckily, as far as I know, the patient suffered no ill effects.  But this could have been an absolute disaster.